The role of pre-hospital blood gas analysis in trauma resuscitation

WORLD JOURNAL OF EMERGENCY SURGERY

Jousi et al. World Journal of Emergency Surgery 2010, 5:10http://www.wjes.org/content/5/1/10

Open AccessR E S E A R C H A R T I C L E

Research articleThe role of pre-hospital blood gas analysis in trauma resuscitationMilla Jousi*1, Janne Reitala1, Vesa Lund2, Ari Katila3 and Ari Leppäniemi4

AbstractBackground: To assess, whether arterial blood gas measurements during trauma patient's pre-hospital shock resuscitation yield useful information on haemodynamic response to fluid resuscitation by comparing haemodynamic and blood gas variables in patients undergoing two different fluid resuscitation regimens.

Methods: In a prospective randomised study of 37 trauma patients at risk for severe hypovolaemia, arterial blood gas values were analyzed at the accident site and on admission to hospital. Patients were randomised to receive either conventional fluid therapy or 300 ml of hypertonic saline. The groups were compared for demographic, injury severity, physiological and outcome variables.

Results: 37 patients were included. Mean (SD) Revised Trauma Score (RTS) was 7.3427 (0.98) and Injury Severity Score (ISS) 15.1 (11.7). Seventeen (46%) patients received hypertonic fluid resuscitation and 20 (54%) received conventional fluid therapy, with no significant differences between the groups concerning demographic data or outcome. Base excess (BE) values decreased significantly more within the hypertonic saline (HS) group compared to the conventional fluid therapy group (mean BE difference -2.1 mmol/l vs. -0.5 mmol/l, p = 0.003). The pH values on admission were significantly lower within the HS group (mean 7.31 vs. 7.40, p = 0.000). Haemoglobin levels were in both groups lower on admission compared with accident site. Lactate levels on admission did not differ significantly between the groups.

Conclusion: Pre-hospital use of small-volume resuscitation led to significantly greater decrease of BE and pH values. A portable blood gas analyzer was found to be a useful tool in pre-hospital monitoring for trauma resuscitation.

BackgroundHemorrhagic shock is commonly defined as a state ofinsufficient perfusion and oxygen supply of vital organsdue to loss of blood volume and impaired cardiac preload[1,2]. In the pre-hospital setting trauma patient's shockresuscitation and its monitoring is usually based on clini-cal experience, assessment and a few basic parameterssuch as level of consciousness, blood pressure, heart rateand capillary filling time. Even if these basic clinicalparameters are close to normal, shock on a cellular ororgan level may be present [3-7]. There is little evidencein the literature on basic intervention strategies of fluidtherapy [8-10,6]. The endpoints of shock resuscitationshould be critically assessed, and resuscitation fromshock considered completed only when anaerobic metab-olism and tissue acidosis have been successfully reversed.

The key therapeutic factor to prevent the development ofmultiple organ failure (MOF) is the normalisation of dis-turbed microvascular perfusion and oxygen supply.

Military experience and clinical and laboratory studiesprovide new knowledge and tools for pre-hospital andearly hospital use to reverse hypovolaemia and hypoxiamore effectively. Early triage, early monitoring, small-vol-ume resuscitation with hypertonic saline, haemoglobin-based oxygen carriers, medical informatics, damage con-trol surgery and definitive interventional radiology can bepromising methods to improve the patient care [8].Repeated measurements of arterial blood gases, lactateand haemoglobin give important information for diagno-sis and follow-up. Serial haemoglobin measurementsassess ongoing bleeding, and signs of metabolic acidosisindicate inadequate oxygen supply and anaerobic metab-olism at cellular level, helping to evaluate the severity ofshock. Pre-hospital blood gas values could as well be con-sidered as a tool for early triage and even as criteria fortrauma team activation in a hospital or a trauma centre.

* Correspondence: milla.jousi@hus.fi1 Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, PL 340, FIN-00029 HUS, FinlandFull list of author information is available at the end of the article

BioMed Central© 2010 Jousi et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

Jousi et al. World Journal of Emergency Surgery 2010, 5:10http://www.wjes.org/content/5/1/10

Page 2 of 7

This study was conducted to assess, whether measure-ments of blood gases before and after pre-hospital fluidresuscitation provide useful information about efficacy ofresuscitation and sufficiency of perfusion and oxygen-ation in the tissues. The second focus of this study was toevaluate the use of small-volume resuscitation with 7.5%hypertonic saline (HS).

MethodsIn this randomised prospective preliminary study wecompared two different pre-hospital fluid resuscitationstrategies for severely injured patients as well as theusability and information provided by a portable bloodgas analyzer. Our study included 37 adult traumapatients, who received pre-hospital care by the helicopteremergency medical system (HEMS) with an emergencyphysician onboard in the surroundings of Helsinki andTurku during the years 1999-2002.

The study inclusion decision was made on the accidentsite. The included patients were estimated to develop pre-hospitally significant hypovolaemia (>1000 ml of bleed-ing). Inclusion criteria were either the actual clinical stateor the mechanism of injury (multiple trauma, penetratingtrauma of the head, neck, chest or abdomen, fracture ofpelvic ring or femur, or a suspicion of injury of large prox-imal vessels of the extremities). Patients, who hadreceived more than 500 ml of crystalloids before initialassessment, were excluded. Because of the difficulty topredict the definitive diagnosis and outcome on the acci-dent site, inclusion criteria were selected to be clear andfast to assess to find the patients in the risk of severehypovolaemia. Not all of them were retrospectively seenas severely injured or hypovolaemic as expected, whichcan be interpreted from the calculated ISS and RTS-val-ues.

The emergency physicians were using a portable clini-cal blood gas analyzer (i-STAT® by Hewlett-Packard, now-adays a product of Abbott Laboratories) on the accidentsite to obtain patients' blood gas values (pH and BE) andhaemoglobin level from the radial or femoral artery.According to the initial base excess (BE) value thepatients were stratified into two groups (BE ≤ -3.0 mmol/l or BE > -3.0 mmol/l). In both of these groups thepatients were further randomised to receive either fluidresuscitation with 300 mL of hypertonic saline (NaCl7.5%, HS) or conventional fluid therapy (crystalloids or/and colloids). The infusion type and amount of pre-hos-pital conventional fluid therapy was decided by the emer-gency physicians, and was influenced by the levels ofshock and transport time. However, the infusion protocolwas essentially same in blunt and penetrating traumapatients. Data about the exact quality and quantity of theconventional fluid therapy was missing from 4 patients,all the other patients received Ringer Acetate (mean 790

ml, range 300-1300) and 7 patients received additionalcolloid therapy (Plasmafucin or hydroxyethylstarch 6%)(mean 380 ml, range 150-500). Hypertonic saline wasadministered regardless of the injury mechanism as infu-sion, which was targeted to end on admission to hospital.Other fluids were interrupted while HS was infused.Orion Pharma produced the hypertonic saline solutionespecially for this study, because at the time of the studyhypertonic saline was not yet registered for pharmacolog-ical use in Finland.

Patient's blood pressure and heart rate were measuredevery 10 minutes during transport to the hospital. Bloodgas values were measured again on admission to hospitalwith a subsequent lactate level measurement.

Revised Trauma Score (RTS) and Injury Severity Score(ISS) were calculated retrospectively based on thepatients' pre-hospital notes and the hospital records [11-14].

Data are presented as mean (standard deviation) forcontinuous and as proportions for discrete values. Con-tinuous variables with normal distribution were analysedwith the Student's t test, and non-normally distributedvariables with the Mann-Whitney U-test. Proportionswere compared with Fisher's exact test. SPSS® statisticssoftware was used for calculations. The statistical signifi-cance level is agreed at p < 0.05.

ResultsSeventeen patients (46%) received hypertonic fluid resus-citation and 20 (54%) conventional fluid therapy. Therewas no statistically significant difference between the twogroups concerning age, sex, mechanism of injury, inci-dence of brain injury, RTS or ISS (Table 1). The mean(SD) age of the patients was 44 (21 - range 16-87) years,29 (78%) of them were male. Four patients (11%) had apenetrating injury (2 gunshot wounds, 1 stabbing, 1explosion), and 33 (89%) had blunt injuries (22 trafficaccidents, 7 falls, 3 compression injuries and one patientinjured by a heavy falling object). The mean RTS was7.3427 (0.98) (range 4.09 - 7.84), and mean ISS was 15.1(11.7) range 1-41). Eighteen patients (49%) were treatedat the Turku University hospital and 19 (51%) at the Hel-sinki University Hospital. Nine patients (24%) had a braininjury. The overall mortality rate was 3 (8%) patients. Theoutcome variables did not differ between the two treat-ment groups (Table 2).

In both groups, the systolic blood pressure and heartrate values increased from the accident site to the time ofthe hospital admission, but there was no differencebetween the two fluid strategy groups (Table 3). In con-trast, the BE levels decreased more within the HS group(mean BE difference -2.1), than in the conventional fluidtherapy group (mean BE difference -0.5) (p = 0.003). ThepH value on admission was significantly lower within the

Jousi et al. World Journal of Emergency Surgery 2010, 5:10http://www.wjes.org/content/5/1/10

Page 3 of 7

HS group (mean 7.31 vs. 7.40, p = 0.000). The haemoglo-bin levels were lower in both groups on admission com-pared to the accident site, and more within the HS group(mean -22 vs. -11, p = 0.016). Lactate levels on admissiondid not differ significantly between the groups (Table 3).

DiscussionThere are numerous studies with different focuses onpre-hospital blood gas analysis in patients undergoing outof hospital cardiopulmonary resuscitation [15-18] or dur-ing emergency transport [19]. In addition, there are sev-eral studies about predictive value of lactate, pH and BEin severely injured trauma patients [20-22], but the mea-surements are all made after admission to a hospital. Inan Austrian prospective study about small-volume resus-

citation, repeated measurements of venous blood electro-lytes, haemoglobin and white cell count were performed,but arterial blood-gas values were not measured [23].This study attempts to obtain more information aboutpre-hospital arterial blood-gas analysis and shock resus-citation of severely injured trauma patients.

Blood lactate levels have been shown to correlate withinjury severity as well as the overall prognosis of theseverely injured patient [20]. Kaplan et al. were able toshow among 282 patients with a major vascular injury,that initial emergency department acid-base variables(pH, base deficit, lactate, anion gap, apparent strong iondifference and strong ion gap) were able to discriminatesurvivors from non-survivors [21]. Sindert et al. pub-lished recently a large study with 489 trauma patients,

Table 1: Patient characteristics

Overall Hypertonic Saline (HS) group

Conventional fluid therapy group

p-value

Number of patients 37 17 (46%) 20 (54%)

Mean patient age in years (SD) 44 (21) 37 (18) 50 (22) 0,074

Number of male patients (percentage) 29 (78%) 12 (71%) 17 (85%) 0,428

Number of female patients (percentage)

8 (22%) 5 (29%) 3 (15%)

Number of patients with blunt trauma (percentage)

33 (89%) 15 (88%) 18 (90%) 1,000

Number of patients with penetrating trauma (percentage)

4 (11%) 2 (12%) 2 (10%)

Number of patients with associated brain injury (percentage)

9 (24%) 5 (29%) 4 (20%) 0,703

Mean Injury Severity Score ISS (SD) 15,1 (11,7) 13,4 (9,5) 16,5 (13,3) 0,614

Mean Revised Trauma Score RTS (SD) 7,343 (0,977) 6,949 (1,302) 7,680 (0,369) 0,084

Mean Glasgow Coma Score GCS (SD) 13,0 (3,2) 12,6 (3,4) 13,3 (3,1) 0,374

Time interval in minutes from trauma to BE-measurement on accident site (SD)

47 (22) 48 (21) 45 (23) 0,372

Time interval in minutes from BE-measurement on accident site to hospital admission (SD)

53 (27) 60 (29) 47 (24) 0,106

Jousi et al. World Journal of Emergency Surgery 2010, 5:10http://www.wjes.org/content/5/1/10

Page 4 of 7

where they were testing the diagnostic utility of Base Def-icit (BD) measurements at triage and four hours later, indistinguishing minor from major injury [22]. Theywanted to test, if infusion of chloride-rich solution, suchas normal saline (NS), confuses the results. Even infusionof more than 2000 ml of normal saline didn't confoundthe prognostic value of BD.

In this study, there were clear differences in BE and pHvalues between the two different fluid strategy groups.The reason for this difference remains unclear. Consider-ing BE and pH values as markers of adequate tissue oxy-genation, conventional fluid therapy appears to be moreeffective than small volume resuscitation in compensat-ing the hypovolaemia. Because 300 ml of hypertonicsaline (NaCl 7.5%) contains 385 mmol of chloride ions(1283 mmol/l), it could cause hyperchloraemic acidosis.Chloride levels were not measured in this study. Therewas no statistically significant difference between the lac-tate levels, which would support some other cause for theacidosis than lactataemia and compromised tissue oxy-genation. The greater decrease of the haemoglobin levelwithin the HS-group is presumably explained by a largerintravascular volume effect of the HS and haemodilution.There is evidence, that infusion of hypertonic saline dex-tran causes metabolic acidosis. Kreimeier and Messmerin their review article suggest, that acidosis after bolusinfusion of hypertonic saline would be due to improve-ment of nutritional blood flow and a wash-out of acidicsubstances and metabolites, rather than only hyperchlo-raemia [24].

There has been an extensive interest in hypertonicsaline during the past few decades because of its ease oftransport, logistical feasibility for military use, speed ofadministration and rapid correction of haemodynamics[25]. In fluid resuscitation the basic mechanism of actionof hypertonic saline is rapid osmotic mobilisation ofwater from intercellular spaces, endothelial cells and red

blood cells into intravascular space. Because cells becomeoedematous during shock, hypertonic saline has beenshown to normalize cell volume rather than reduce itbelow normal. Infusion of hypertonic saline dilates arteri-oles and reduces peripheral and pulmonary vascularresistance by directly relaxing smooth muscle anddecreasing blood viscosity. Heart rate and cardiac con-tractility are both increased, and all that synergisticallyincreases cardiac output and oxygen delivery to the tis-sues [24-26]. Combining a colloid component to hyper-tonic saline, nowadays most frequently 6% dextran 70,results in a significantly higher cardiac output and moresustained plasma volume expansion. In recent animal andin vitro studies hypertonicity has been found to affectimmune responses of trauma, shock and reperfusion bysuppressing several neutrophil functions and up-regulat-ing T-lymphocyte functions. Hypertonic saline has beenshown to cause key alterations in interactions of poly-morphonuclear neutrophils and endothelial cells, whichunder shock conditions (mediated by proteases and freeoxygen radicals) are partly responsible for developmentof systemic inflammatory response syndrome (SIRS).Also, hypertonic saline has been shown to decreasemicrovascular permeability [25,27]. Hypertonic salinecould be considered both as a resuscitation fluid forrestoring intravascular volume as well as an immuno-modulator to prevent later complications, such as multi-ple organ failure (MOF).

Even if there is evidence of hypertonic resuscitationconcerning safety [23,28,29] and effectiveness in restor-ing macrovascular haemodynamics, large human clinicaltrials have not yet been able to demonstrate consistentlybenefit in terms of morbidity or mortality [30-32]. Theresults about long-term benefit for patients with trau-matic brain injury are contradictory [33-35]. On the otherhand patients, who were hypotensive and required sur-gery because of penetrating injuries to the torso, had

Table 2: Outcome

Overall Hypertonic Saline (HS) group

Conventional fluid therapy group

p-value

Mortality (percentage) 3 (8%) 1 (6%) 2 (10%) 1.000

Transfused red blood cell units (SD)

5.4 (8.5) 4.4 (8.7) 6.2 (8.3) 0.416

Duration of intensive care in days (SD)

5 (8) 5 (7) 6 (9) 0.670

Duration of hospital care in days (SD)

25 (43) 15 (12) 34 (57) 0.891

Jousi et al. World Journal of Emergency Surgery 2010, 5:10http://www.wjes.org/content/5/1/10

Page 5 of 7

Table 3: Results

Overall Hypertonic Saline (HS) group

Conventional fluid therapy group

p-value

Mean of Systolic Blood Pressure values on accident site in mmHg (SD)

122 (29) 118 (32) 125 (26) 0.293

Mean of Systolic Blood Pressure values on admission to hospital in mmHg (SD)

141 (26) 141 (26) 141 (28) 0.945

Mean of change in Systolic Blood Pressure values in mmHg between accident site and admission to hospital (SD)

21 (30) 27 (35) 17 (26) 0.652

Mean of Heart rate values (beats per minute) on accident site (SD)

86 (20) 86 (20) 86 (22) 0.976

Mean of Heart rate values on admission to hospital (SD) 93 (25) 99 (23) 88 (25) 0.241

Mean of change in Heart rate values between accident site and admission to hospital (SD)

7 (17) 12 (20) 3 (14) 0.248

Mean of Base Excess values (BE) (mmol/L) on accident site (SD)

-2.6 (4.0) -2.8 (4.1) -2.4 (4.1) 0.866

Mean of Base Excess values (BE) (mmol/L) on admission to hospital (SD)

-3.3 (3.4) -5.0 (2.8) -1.9 (3.3) 0.008 *

Mean of differences in Base Excess values between accident site and admission to hospital (SD)

-0.6 (2.8) -2.1 (2.6) -0.5 (2.4) 0.003 *

Mean of pH values on accident site (SD) 7.38 (0.09) 7.35 (0.11) 7.41 (0.07) 0.205

Mean of pH values on admission to hospital (SD) 7.36 (0.08) 7.31 (0.07) 7.40 (0.06) 0.000 *

Mean of differences in pH values between accident site and admission to hospital (SD)

-0.03 (0.09) -0.04 (0.12) -0.01 (0.05) 0.196

Mean of Haemoglobin values (Hb) (g/L) on accident site (SD)

135 (17) 135 (17) 135 (17) 0.963

Mean of Haemoglobin values (Hb) (g/L) on admission to hospital (SD)

119 (19) 114 (20) 124 (17) 0.074

Mean of differences in Haemoglobin values between accident site and admission to hospital (SD)

-16 (14) -22 (14) -11 (12) 0.016 *

Mean of patient Lactate levels (mmol/L) on admission to hospital (SD)

2.34 (1.37) 2.21 (1.26) 2.46 (1.49) 0.871

Jousi et al. World Journal of Emergency Surgery 2010, 5:10http://www.wjes.org/content/5/1/10

Page 6 of 7

improved survival if they received hypertonic salineinstead of conventional fluid therapy [36]. Mortalitymight though not represent the optimal end point forstudies for small-volume resuscitation. Rather, measuresof organ dysfunction might show its real benefits [24,37].

We found out some weaknesses in our study setting.One is, that despite of the tight inclusion criteria, whichwere supposed to find the hypovolaemic patients, manyof them were though not severely injured, as can be seenwith ISS and RTS-values. Another confusing factor is thevariety of pre-hospital circumstances. The two emer-gency helicopters are covering a very large geographicalarea with varying quality of baseline emergency services.Patients from remote locations are though transportedprimarily to Level 1 Trauma Centre with an ambulanceand an emergency physician, which causes sometimesrelatively long pre-hospital times.

Studies with more patients are needed to show the realreason and significance of the differences in BE and pHvalues between the patients receiving different types offluid resuscitation. Electrolyte measurements with blood-gas values are needed to determine more precisely thetype of acidosis. Correlation between injury severity andinitial pre-hospital BE and pH could be examined inorder to consider blood-gas values as a tool for triage.Taking arterial blood samples and using a portable clini-cal blood gas analyzer at the accident site requires addi-tional time and efforts from the emergency physician,and its usefulness should be judged in view of the overalltime and resource utilization. This study, however, showsthat arterial blood gas analyses in the field are feasibleand could be used in the future for better en-route man-agement and triage for severely injured patients.

ConclusionsPre-hospital arterial blood gas measurements duringtrauma patient's fluid resuscitation by emergency physi-cian based helicopter emergency medical system (HEMS)provided useful information about patients' acid-basevalues. Comparing the values after either conventionalfluid therapy or small-volume resuscitation with hyper-tonic saline demonstrated, that the use of small-volumeresuscitation lead to significantly greater decrease in theBE and pH values. The reason for this remains unclear. Aportable clinical blood gas analyzer (i-STAT® by Hewlett-Packard) was found to be a usable tool for pre-hospitalmonitoring of trauma resuscitation.

Competing interestsThe authors declare that they have no competing interests.

Authors' contributionsJR, VL, AK and AL have been participating in the study design. JR, VL and AKhave been participating in the data collecting on field. MJ performed the datacollection from the patient files, performed the statistical analysis and com-

pleted the manuscript with the support of AL. All authors have read andapproved the final manuscript.

Author Details1Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, PL 340, FIN-00029 HUS, Finland, 2Intensive Care Unit, Satakunta Central Hospital, Sairaalantie 3, FIN-28500 Pori, Finland, 3Department of Anaesthesiology and Intensive Care Medicine, Turku University Hospital, PL 52, FIN-20521 Turku, Finland and 4Department of Surgery, Helsinki University Hospital, PL 340, FIN-00029 HUS, Finland

References1. Wiggers HC, Ingraham RC: Hemorrhagic shock: definition and criteria

for its diagnosis. J Clin Invest 1946, 25(1):30-36.2. Adams HA, Baumann G, Gansslen A, Janssens U, Knoefel W, Koch T, Marx

G, Muller-Werdan U, Pape HC, Prange W, Roesner D, Standl T, Teske W, Werner G, Zander R: Definition of shock types. Anaesthesiol Intensivmed Notfallmed Schmerzther 2001, 36(11 Suppl 2):S140-3.

3. Dabrowski GP, Steinberg SM, Ferrara JJ, Flint LM: A critical assessment of endpoints of shock resuscitation. Surg Clin North Am 2000, 80(3):825-44.

4. McKinley BA, Valdivia A, Moore FA: Goal-oriented shock resuscitation for major torso trauma: what are we learning? Curr Opin Crit Care 2003, 9(4):292-9.

5. Porter JM, Ivantury RR: In search of the optimal end points of resuscitation in trauma patients: a review. J Trauma 1998, 44(5):908-14.

6. Kreimeier U, Messmer K: Prehospital fluid resuscitation: a review. Anaesthetist 1996, 45(10):884-99.

7. McGee S, Abernethy WB, Simel DL: The rational clinical examination. Is the patient hypovolemic? JAMA 1999, 281:1022-9.

8. Moore FA, McKinley BA, Moore EE: The next generation in shock resuscitation. Lancet 2004, 363:1988-96.

9. Gosling P: Salt of the earth or a drop in the ocean? A patophysiological approach to fluid resuscitation: a review. Emerg Med J 2003, 20:306-315.

10. Wilson M, Davis DP, Coimbra R: Diagnosis and monitoring of hemorrhagic shock during the initial resuscitation of multiple trauma patients: a review. J Emerg Med 2003, 24(4):413-22.

11. The Association for the Advancement of Automotive Medicine (AAAM), Committee on Injury Scaling: Abbreviated Injury Scale (AIS). 1990.

12. Champion HR, Copes WS, Sacco WJ, Lawnick MM, Keast SL, Bain LW Jr, Flanagan ME, Frey CF: The Major Trauma Outcome Study: establishing national norms for trauma care. J Trauma 1990, 30(11):1356-65.

13. Baker SP, O'Neill B, Haddon W, Long WB: The Injury Severity Score: A method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974, 14:187-196.

14. Moore L, Lavoie A, LeSage N, Abdous B, Bergeron E, Liberman M, Edmond M: Statistical validation of the Revised Trauma Score. J Trauma 2006, 60(2):305-11.

15. Prause G, Hetz H, Doppler R: Preclinical blood gas analysis. 1. The value of preclinical blood gas analysis. Anaesthesist 1998, 47(5):400-5.

16. Hetz H, Prause G, Tesar H, List WF: Preclinical blood gas analysis. Technical description - initial experiences - indications. Anaesthesist 1996, 45(8):750-4.

17. Takasu A, Sakamoto T, Okada Y: Arterial base excess after CPR: The relationship to CPR duration and the characteristics related to outcome. Resuscitation 2007, 73(3):394-9.

18. Prause G, Ratzenhofer-Comenda B, Smolle-Juttner F, Heydar-Fadai J, Wildner G, Spernbauer P, Smolle J, Hetz H: Comparison of lactate or BE during out-of-hospital cardiac arrest to determine metabolic acidosis. Resuscitation 2001, 51(3):297-300.

19. Prause G, Ratzenhofer-Komenda B, Offner A, Lauda P, Voit H, Pojer H: Prehospital point of care testing of blood gases and electrolytes - en evaluation of IRMA. Crit Care 1997, 1(2):79-83.

20. Cerovic O, Golubovic V, Spec-Marn A, Kremzar B, Vidmar G: Relationship between injury severity and lactate levels in severly injured patients. Intensive Care Med 2003, 29:1300-05.

21. Kaplan LJ, Kellum JA: Initial pH, base deficit, lactate, anion gap, strong ion difference, and strong ion gap predict outcome from major vascular injury. Crit Care Med 2004, 32(5):1120-24.

Received: 11 January 2010 Accepted: 22 April 2010 Published: 22 April 2010This article is available from: http://www.wjes.org/content/5/1/10© 2010 Jousi et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.World Journal of Emergency Surgery 2010, 5:10

Jousi et al. World Journal of Emergency Surgery 2010, 5:10http://www.wjes.org/content/5/1/10

Page 7 of 7

22. Sinert R, Zehtabchi S, Bloem C, Lucchesi M: Effect of normal saline infusion on the diagnostic utility of base deficit in identifying major injury in trauma patients. Acad Emerg Med 2006, 13:1269-74.

23. Mauritz W, Schimetta W, Oberreither S, Polz W: Are hypertonic solutions safe for prehospital small-volume resuscitation? Results of a prospective observational study. Eur J Emerg Med 2002, 9(4):315-19.

24. Kreimeier U, Messmer K: Small-volume resuscitation: from experimental evidence to clinical routine. Advantages and disadvantages of hypertonic solutions. A Review Article. Acta Anaesthesiol Scand 2002, 46:625-638.

25. Pasqual JL, Khwaja KA, Chaudhury P, Christou NV: Hypertonic saline and microsirculation. J Trauma 2003, 54(5):S133-40.

26. Kramer GC: Hypertonic resuscitation: physiologic mechanisms and recommendations for trauma care. J Trauma 2003, 54:S89-99.

27. Kølsen-Petersen JA: Immune effect of hypertonic saline: fact or fiction? A review article. Acta Anaesthesiol Scand 2004, 48:667-78.

28. Schimetta W, Schöchl H, Kröll W, Pölz W, Pölz G, Mauritz W: Safety of hypertonic solutions - A survey from Austria. Wien Klin Wochenschr 2002, 114(3):89-95.

29. Vassar MJ, Perry CA, Holcroft JW: Analysis of potential risks associated with 7,5% sodium chloride resuscitation of traumatic shock. Arch Surg 1990, 125(10):1309-15.

30. Hypertonic versus near isotonic crystalloid for fluid resuscitation in critically ill patients. Cochrane Database of Systematic Reviews 4 2004.

31. Kreimeier U, Christ F, Frey L, Habler O, Thiel M, Welte M, Zwissler B, Peter K: Small-volume resuscitation for hypovolemic shock. Concept, experimental and clinical results. Anaesthesist 1997, 46(4):309-28.

32. Wade CE, Kramer GC, Grady JJ, Fabian TC, Younes RN: Efficacy of hypertonic 7,5% saline and 6% dextran-70 in treating trauma: a meta-analysis of controlled clinical studies. Surgery 1997, 122(3):609-16.

33. Wade CE, Grady JJ, Kramer GC, Younes RN, Gehlsen K, Holcroft JW: Individual patient cohort analysis of the efficacy of hypertonic saline/dextran in patients with traumatic brain injury and hypotension. J Trauma 1997, 42(5):S61-65.

34. Cooper DJ, Myles PS, McDermott FT, Murray LJ, Laidlaw J, Cooper G, Tremayne AB, Bernard SS, Ponsdorf J: Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury. JAMA 2004, 291(11):1350-57.

35. Doyle JA, Davis DP, Hoyt DB: The use of hypertonic saline in the treatment of traumatic brain injury: a review. J Trauma 2001, 50(2):367-83.

36. Wade CE, Grady JJ, Kramer GC: Efficacy of hypertonic saline dextran fluid resuscitation for patients with hypotension from penetrating trauma. J Trauma 2003, 54:S144-48.

37. Rotstein OD: Novel strategies for immunomodulation after trauma: Revisiting hypertonic saline as a resuscitation strategy for hemorrhagic shock. J Trauma 2000, 49:580-583.

doi: 10.1186/1749-7922-5-10Cite this article as: Jousi et al., The role of pre-hospital blood gas analysis in trauma resuscitation World Journal of Emergency Surgery 2010, 5:10